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Valdivielso JM, Balafa O, Ekart R, Ferro CJ, Mallamaci F, Mark PB, Rossignol P, Sarafidis P, Del Vecchio L, Ortiz A. Hyperkalemia in Chronic Kidney Disease in the New Era of Kidney Protection Therapies. Drugs 2021; 81:1467-1489. [PMID: 34313978 DOI: 10.1007/s40265-021-01555-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 12/20/2022]
Abstract
Despite recent therapeutic advances, chronic kidney disease (CKD) is one of the fastest growing global causes of death. This illustrates limitations of current therapeutic approaches and, potentially, unidentified knowledge gaps. For decades, renin-angiotensin-aldosterone system (RAAS) blockers have been the mainstay of therapy for CKD. However, they favor the development of hyperkalemia, which is already common in CKD patients due to the CKD-associated decrease in urinary potassium (K+) excretion and metabolic acidosis. Hyperkalemia may itself be life-threatening as it may trigger potentially lethal arrhythmia, and additionally may limit the prescription of RAAS blockers and lead to low-K+ diets associated to low dietary fiber intake. Indeed, hyperkalemia is associated with adverse kidney, cardiovascular, and survival outcomes. Recently, novel kidney protective therapies, ranging from sodium/glucose cotransporter 2 (SGLT2) inhibitors to new mineralocorticoid receptor antagonists have shown efficacy in clinical trials. Herein, we review K+ pathophysiology and the clinical impact and management of hyperkalemia considering these developments and the availability of the novel K+ binders patiromer and sodium zirconium cyclosilicate, recent results from clinical trials targeting metabolic acidosis (sodium bicarbonate, veverimer), and an increasing understanding of the role of the gut microbiota in health and disease.
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Affiliation(s)
- José M Valdivielso
- Vascular and Renal Translational Research Group, UDETMA, REDinREN del ISCIII, IRBLleida, Lleida, Spain.
| | - Olga Balafa
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | - Robert Ekart
- Clinic for Internal Medicine, Department of Dialysis, University Medical Center Maribor, Maribor, Slovenia
| | - Charles J Ferro
- Department of Renal Medicine, University Hospitals Birmingham, Edgbaston, Birmingham, UK
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases, Ospedali Riuniti, 89124, Reggio Calabria, Italy
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Patrick Rossignol
- Inserm 1433 CIC-P CHRU de Nancy, Inserm U1116 and FCRIN INI-CRCT, Université de Lorraine, Nancy, France
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Como, Italy
| | - Alberto Ortiz
- School of Medicine, IIS-Fundacion Jimenez Diaz, University Autonoma of Madrid, FRIAT and REDINREN, Madrid, Spain
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2
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Karaboyas A, Robinson BM, James G, Hedman K, Moreno Quinn CP, De Sequera P, Nitta K, Pecoits-Filho R. Hyperkalemia excursions are associated with an increased risk of mortality and hospitalizations in hemodialysis patients. Clin Kidney J 2021; 14:1760-1769. [PMID: 34221383 PMCID: PMC8243282 DOI: 10.1093/ckj/sfaa208] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/31/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Hyperkalemia is common among hemodialysis (HD) patients and has been associated with adverse clinical outcomes. Previous studies considered a single serum potassium (K) measurement or time-averaged values, but serum K excursions out of the target range may be more reflective of true hyperkalemia events. We assessed whether hyperkalemia excursions lead to an elevated risk of adverse clinical outcomes. METHODS Using data from 21 countries in Phases 4-6 (2009-18) of the Dialysis Outcomes and Practice Patterns Study (DOPPS), we investigated the associations between peak serum K level, measured monthly predialysis, over a 4-month period ('peak K') and clinical outcomes over the subsequent 4 months using Cox regression, adjusted for potential confounders. RESULTS The analysis included 62 070 patients contributing a median of 3 (interquartile range 2-6) 4-month periods. The prevalence of hyperkalemia based on peak K was 58% for >5.0, 30% for >5.5 and 12% for >6.0 mEq/L. The all-cause mortality hazard ratio for peak K (reference ≤5.0 mEq/L) was 1.15 [95% confidence interval (CI) 1.09, 1.21] for 5.1-5.5 mEq/L, 1.19 (1.12, 1.26) for 5.6-6.0 mEq/L and 1.33 (1.23, 1.43) for >6.0 mEq/L. Results were qualitatively consistent when analyzing hospitalizations and a cardiovascular composite outcome. CONCLUSIONS Among HD patients, we identified a lower K threshold (peak K 5.1-5.5 mEq/L) than previously reported for increased risk of hospitalization and mortality, with the implication that a greater proportion (>50%) of the HD population may be at risk. A reassessment of hyperkalemia severity ranges is needed, as well as an exploration of new strategies for effective management of chronic hyperkalemia.
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Affiliation(s)
| | - Bruce M Robinson
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Glen James
- BioPharmaceuticals Medical, AstraZeneca, Cambridge, UK
| | - Katarina Hedman
- BioPharmaceuticals Business Unit, AstraZeneca, Gothenburg, Sweden
| | | | | | - Kosaku Nitta
- Department of Nephrology, Tokyo Women's Medical University, Shinjuku, Tokyo, Japan
| | - Roberto Pecoits-Filho
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
- School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil
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3
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Krogager ML, Kragholm K, Thomassen JQ, Søgaard P, Lewis BS, Wassmann S, Baumgartner I, Ceconi C, Schmidt TA, Kaski JC, Drexel H, Semb AG, Agewall S, Niessner A, Savarese G, Kjeldsen KP, Borghi C, Tamargo J, Torp-Pedersen C. Update on management of hypokalemia and goals for the lower potassium level in patients with cardiovascular disease: A review in collaboration with the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 7:557-567. [PMID: 33956964 DOI: 10.1093/ehjcvp/pvab038] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 05/04/2021] [Indexed: 11/14/2022]
Abstract
Abstract
Hypokalaemia is common in patients with cardiovascular disease. In this review, we emphasize the importance of tight potassium regulation in patients with cardiovascular disease based on findings from observational studies. To enhance the understanding, we also describe the mechanisms of potassium homeostasis maintenance, the most common causes of hypokalaemia and present strategies for monitoring and management of low potassium levels. We propose elevation of potassium in asymptomatic patients with lower normal concentrations and concurrent cardiovascular disease. These proposals are intended to assist clinicians until more evidence is available.
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Affiliation(s)
| | - Kristian Kragholm
- Department of Cardiology, Aalborg University hospital, Aalborg, Denmark.,Department of Cardiology, Region Hospital North Jutland, Hjørring, Denmark.,Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Jesper Qvist Thomassen
- Department of Clinical Biochemistry, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - Peter Søgaard
- Department of Cardiology, Aalborg University hospital, Aalborg, Denmark
| | - Basil S Lewis
- Lady Davis Carmel Medical Center and the Ruth and Bruce Rappaport School of Medicine, Technion-IIT, Haifa, Israel
| | - Sven Wassmann
- Cardiology Pasing, Munich, Germany and University of the Saarland, Homburg/Saar, Germany
| | - Iris Baumgartner
- Department of Angiology, Bern University Hospital (Inselspital), Bern, Switzerland
| | - Claudio Ceconi
- Department of Cardiology, Desenzano Del Garda Hospital, Italy
| | - Thomas Andersen Schmidt
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,The Emergency Department, North Zealand University Hospital, Hillerød, Denmark
| | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK
| | - Heinz Drexel
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Landeskrankenhaus, Feldkirch, Austria.,Private University of the Principality of Liechtenstein, Triesen, Liechtenstein.,Drexel University College of Medicine, Philadelphia, PA, USA
| | - Anne Grete Semb
- Preventive Cardio-Rheuma clinic, Depatment Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Stefan Agewall
- Department of Cardiology, Ullevål, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Sciences, Søsterhjemmet, University of Oslo, Oslo, Norway
| | - Alexander Niessner
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Instituttet, Stockholm, Sweden
| | - Keld Per Kjeldsen
- Department of Cardiology, Copenhagen University Hospital (Amager-Hvidovre), Copenhagen, Denmark.,Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Claudio Borghi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Juan Tamargo
- Department of Pharmacology, School of Medicine, CIBERCV, University Complutense, 28040, Madrid, Spain
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4
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Wiśniowska B, Bielecka ZM, Polak S. How circadian variability of the heart rate and plasma electrolytes concentration influence the cardiac electrophysiology - model-based case study. J Pharmacokinet Pharmacodyn 2021; 48:387-399. [PMID: 33666801 PMCID: PMC8144092 DOI: 10.1007/s10928-021-09744-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 02/24/2021] [Indexed: 11/24/2022]
Abstract
The circadian rhythm of cardiac electrophysiology is dependent on many physiological and biochemical factors. Provided, that models describing the circadian patterns of cardiac activity and/or electrophysiology which have been verified to the acceptable level, modeling and simulation can give answers to many of heart chronotherapy questions. The aim of the study was to assess the performance of the circadian models implemented in Cardiac Safety Simulator v 2.2 (Certara, Sheffield, UK) (CSS), as well as investigate the influence ofcircadian rhythms on the simulation results in terms of cardiac safety. The simulations which were run in CSS accounted for inter-individual and intra-individual variability. Firstly, the diurnal variations in QT interval length in a healthy population were simulated accounting for heart rate (HR) circadian changes alone, or with concomitant diurnal variations of plasma ion concentrations. Next, tolterodine was chosen as an exemplary drug for PKPD modelling exercise to assess the role of circadian rhythmicity in the prediction of drug effects on QT interval. The results of the simulations were in line with clinical observations, what can serve as a verification of the circadian models implemented in CSS. Moreover, the results have suggested that the circadian variability of the electrolytes balance is the main factor influencing QT circadian pattern. The fluctuation of ion concentration increases the intra-subject variability of predicted drug-triggered QT corrected for HR (QTc) prolongation effect and, in case of modest drug effect on QTc interval length, allows to capture this effect.
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Affiliation(s)
- Barbara Wiśniowska
- Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9 Street, 30-688, Kraków, Poland.
| | - Zofia M Bielecka
- Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9 Street, 30-688, Kraków, Poland
- Simcyp Division, Certara UK Limited, Level 2-Acero, 1 Concourse Way, Sheffield, S1 2BJ, UK
| | - Sebastian Polak
- Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9 Street, 30-688, Kraków, Poland
- Simcyp Division, Certara UK Limited, Level 2-Acero, 1 Concourse Way, Sheffield, S1 2BJ, UK
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5
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Kashihara N, Nishio T, Osonoi T, Saka Y, Imasawa T, Ohtake T, Mizuno H, Shibagaki Y, Kim H, Yajima T, Sarai N. Correction of serum potassium with sodium zirconium cyclosilicate in Japanese patients with hyperkalemia: a randomized, dose-response, phase 2/3 study. Clin Exp Nephrol 2020; 24:1144-1153. [PMID: 32779057 PMCID: PMC7599176 DOI: 10.1007/s10157-020-01937-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/19/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Sodium zirconium cyclosilicate (SZC) is an oral potassium binder approved to treat hyperkalemia in adults in a number of countries, including Japan. METHODS This phase 2/3, randomized, double-blind, placebo-controlled, dose-response study (ClinicalTrials.gov: NCT03127644) was designed to determine the efficacy and safety of SZC in Japanese adults with hyperkalemia. Patients with serum potassium (sK+) concentrations ≥ 5.1- ≤ 6.5 mmol/L were randomized 1:1:1 to SZC 5 g, SZC 10 g, or placebo three times daily for 48 h (six doses total). The primary efficacy endpoint was the exponential rate of change in sK+ over 48 h. The proportion of patients with normokalemia (sK+ 3.5-5.0 mmol/L) at 48 h and adverse events (AEs) were also evaluated. RESULTS Overall, 103 patients (mean age, 73.2 years; range 50-89 years) received SZC 5 g (n = 34), SZC 10 g (n = 36), or placebo (n = 33). The exponential rate of sK+ change from 0 to 48 h versus placebo was - 0.00261 (SZC 5 g) and - 0.00496 (SZC 10 g; both P < 0.0001). At 48 h, the proportions of patients with normokalemia were 85.3%, 91.7%, and 15.2% with SZC 5 g, SZC 10 g, and placebo, respectively. No serious AEs were reported. Hypokalemia (sK+ < 3.5 mmol/L) occurred in two patients in the SZC 10 g group; normokalemia was re-established within 6 days and no treatment-related AEs were reported. CONCLUSION SZC is effective and well tolerated in Japanese patients with hyperkalemia.
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Affiliation(s)
- Naoki Kashihara
- Department of Nephrology and Hypertension, Kawasaki Medical School, Okayama, Japan
| | - Toshiki Nishio
- Nephrology Dialysis Center, Kusatsu General Hospital, Shiga, Japan
| | - Takeshi Osonoi
- Department of Internal Medicine, Nakakinen Clinic, Ibaraki, Japan
| | - Yosuke Saka
- Department of Nephrology, Kasugai Municipal Hospital, Aichi, Japan
| | | | - Takayasu Ohtake
- Department of Nephrology, Shonan Kamakura General Hospital, Kanagawa, Japan
| | | | - Yugo Shibagaki
- Division of Nephrology and Hypertension, St. Marianna University School of Medicine Hospital, Kanagawa, Japan
| | - Hyosung Kim
- Research and Development, AstraZeneca K.K, 1-8-3, Marunouchi, Chiyoda-ku, Tokyo, 100-0005, Japan
| | - Toshitaka Yajima
- Research and Development, AstraZeneca K.K, 1-8-3, Marunouchi, Chiyoda-ku, Tokyo, 100-0005, Japan
| | - Nobuaki Sarai
- Research and Development, AstraZeneca K.K, 1-8-3, Marunouchi, Chiyoda-ku, Tokyo, 100-0005, Japan.
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6
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Giil LM, Solvang SEH, Giil MM, Hellton KH, Skogseth RE, Vik-Mo AO, Hortobágyi T, Aarsland D, Nordrehaug JE. Serum Potassium Is Associated with Cognitive Decline in Patients with Lewy Body Dementia. J Alzheimers Dis 2019; 68:239-253. [PMID: 30775974 DOI: 10.3233/jad-181131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Epidemiological studies link serum potassium (K+) to cognitive performance, but whether cognitive prognosis in dementia is related to K+ levels is unknown. OBJECTIVE To determine if K+ levels predict cognitive prognosis in dementia and if this varies according to diagnosis or neuropathological findings. METHODS This longitudinal cohort study recruited 183 patients with mild Alzheimer's disease or Lewy body dementia (LBD). Serum K+ and eGFR were measured at baseline and medications which could affect K+ registered. The Mini-Mental State Examination (MMSE) was measured annually over 5 years, and mortality registered. Association between K+ and √(30 -MMSE) was estimated overall, and according to diagnosis (joint model). Associations between MMSE-decline and K+ were assessed in two subgroups with neuropathological examination (linear regression) or repeated measurements of K+ over 3 years (mixed model). RESULTS Serum K+ at baseline was associated with more errors on MMSE over time (Estimate 0.18, p = 0.003), more so in LBD (p = 0.048). The overall association and LBD interaction were only significant in the 122 patients not using K+ relevant medication. Repeated K+ measures indicated that the association with MMSE errors over time was due to a between-person effect (p < 0.05, n = 57). The association between the annual MMSE decline was stronger in patients with autopsy confirmed LBD and more α-synuclein pathology (all: p < 0.05, n = 41). CONCLUSION Higher serum K+ predicts poorer cognitive prognosis in demented patients not using medications which affect K+, likely a between-person effect seen mainly in LBD.
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Affiliation(s)
- Lasse Melvaer Giil
- Department of Internal Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway.,Institute of Clinical Sciences, University of Bergen, Norway
| | - Stein-Erik Hafstad Solvang
- Department of Internal Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway.,Institute of Clinical Sciences, University of Bergen, Norway
| | | | | | - Ragnhild Eide Skogseth
- Department of Internal Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Bergen, Norway
| | - Audun Osland Vik-Mo
- Institute of Clinical Sciences, University of Bergen, Norway.,Center for Age-Related Diseases (SESAM), Stavanger University Hospital, Norway
| | - Tibor Hortobágyi
- MTA-DE Cerebrovascular and Neurodegenerative Research Group, University of Debrecen, Debrecen, Hungary.,Department of Old Age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, Kings College, UK
| | - Dag Aarsland
- Center for Age-Related Diseases (SESAM), Stavanger University Hospital, Norway.,Department of Old Age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, Kings College, UK
| | - Jan Erik Nordrehaug
- Department of Internal Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway.,Institute of Clinical Sciences, University of Bergen, Norway
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7
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Bakhai A, Palaka E, Linde C, Bennett H, Furuland H, Qin L, McEwan P, Evans M. Development of a health economic model to evaluate the potential benefits of optimal serum potassium management in patients with heart failure. J Med Econ 2018; 21:1172-1182. [PMID: 30160541 DOI: 10.1080/13696998.2018.1518239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
AIMS Patients with heart failure are at increased risk of hyperkalemia, particularly when treated with renin-angiotensin-aldosterone system inhibitor (RAASi) agents. This study developed a model to quantify the potential health and economic value associated with sustained potassium management and optimal RAASi therapy in heart failure patients. MATERIALS AND METHODS A patient-level, fixed-time increment stochastic simulation model was designed to characterize the progression of heart failure through New York Heart Association functional classes, and predict associations between serum potassium levels, RAASi use, and consequent long-term outcomes. Following internal and external validation exercises, model analyses sought to quantify the health and economic benefits of optimizing both serum potassium levels and RAASi therapy in heart failure patients. Analyses were conducted using a UK payer perspective, independent of costs and utilities related to pharmacological potassium management. RESULTS Validation against multiple datasets demonstrated the predictive capability of the model. Compared to those who discontinued RAASi to manage serum potassium, patients with normokalemia and ongoing RAASi therapy benefited from longer life expectancy (+1.38 years), per-patient quality-adjusted life year gains (+0.53 QALYs), cost savings (£110), and associated net monetary benefit (£10,679 at £20,000 per QALY gained) over a lifetime horizon. The predicted value of sustained potassium management and ongoing RAASi treatment was largely driven by reduced mortality and hospitalization risks associated with optimal RAASi therapy. LIMITATIONS Several modeling assumptions were made to account for a current paucity of published literature; however, ongoing refinement and validation of the model will ensure its continued accuracy as the clinical landscape of hyperkalemia evolves. CONCLUSIONS Predictions generated by this novel modeling approach highlight the value of sustained potassium management to avoid hyperkalemia, enable RAASi therapy, and improve long-term health economic outcomes in patients with heart failure.
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Affiliation(s)
- Ameet Bakhai
- a Department of Cardiology , Royal Free Hospital , London , UK
| | - Eirini Palaka
- b Global Health Economics, AstraZeneca , Cambridge , UK
| | - Cecilia Linde
- c Heart and Vascular Theme , Karolinska University Hospital and Karolinska Institutet , Stockholm , Sweden
| | - Hayley Bennett
- d Health Economics and Outcomes Research Ltd , Cardiff , UK
| | - Hans Furuland
- e Department of Nephrology , Uppsala University Hospital , Uppsala , Sweden
| | - Lei Qin
- f Global Health Economics, AstraZeneca , Gaithersburg , MD , USA
| | - Phil McEwan
- d Health Economics and Outcomes Research Ltd , Cardiff , UK
- g School of Human and Health Sciences , Swansea University , Swansea , UK
| | - Marc Evans
- h Diabetes Resource Centre , Llandough Hospital , Cardiff , UK
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8
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Kervezee L, Gotta V, Stevens J, Birkhoff W, Kamerling I, Danhof M, Meijer JH, Burggraaf J. Levofloxacin-Induced QTc Prolongation Depends on the Time of Drug Administration. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2016; 5:466-74. [PMID: 27479699 PMCID: PMC5036421 DOI: 10.1002/psp4.12085] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 04/24/2016] [Indexed: 12/21/2022]
Abstract
Understanding the factors influencing a drug's potential to prolong the QTc interval on an electrocardiogram is essential for the correct evaluation of its safety profile. To explore the effect of dosing time on drug‐induced QTc prolongation, a randomized, crossover, clinical trial was conducted in which 12 healthy male subjects received levofloxacin at 02:00, 06:00, 10:00, 14:00, 18:00, and 22:00. Using a pharmacokinetic‐pharmacodynamic (PK‐PD) modeling approach to account for variations in PKs, heart rate, and daily variation in baseline QT, we find that the concentration‐QT relationship shows a 24‐hour sinusoidal rhythm. Simulations show that the extent of levofloxacin‐induced QT prolongation depends on dosing time, with the largest effect at 14:00 (1.73 (95% prediction interval: 1.56–1.90) ms per mg/L) and the smallest effect at 06:00 (−0.04 (−0.19 to 0.12) ms per mg/L). These results suggest that a 24‐hour variation in the concentration‐QT relationship could be a potentially confounding factor in the assessment of drug‐induced QTc prolongation.
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Affiliation(s)
- L Kervezee
- Laboratory for Neurophysiology, Department of Molecular Cell Biology, Leiden University Medical Center, Leiden, The Netherlands.,Centre for Human Drug Research, Leiden, The Netherlands.,Division of Pharmacology, Leiden Academic Center for Drug Research, Leiden University, Leiden, The Netherlands
| | - V Gotta
- Division of Pharmacology, Leiden Academic Center for Drug Research, Leiden University, Leiden, The Netherlands
| | - J Stevens
- Centre for Human Drug Research, Leiden, The Netherlands
| | - W Birkhoff
- Centre for Human Drug Research, Leiden, The Netherlands
| | - Imc Kamerling
- Centre for Human Drug Research, Leiden, The Netherlands
| | - M Danhof
- Division of Pharmacology, Leiden Academic Center for Drug Research, Leiden University, Leiden, The Netherlands
| | - J H Meijer
- Laboratory for Neurophysiology, Department of Molecular Cell Biology, Leiden University Medical Center, Leiden, The Netherlands
| | - J Burggraaf
- Centre for Human Drug Research, Leiden, The Netherlands. .,Division of Pharmacology, Leiden Academic Center for Drug Research, Leiden University, Leiden, The Netherlands.
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9
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Patiromer induces rapid and sustained potassium lowering in patients with chronic kidney disease and hyperkalemia. Kidney Int 2015; 88:1427-1433. [PMID: 26376130 PMCID: PMC4678168 DOI: 10.1038/ki.2015.270] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 07/21/2015] [Accepted: 07/24/2015] [Indexed: 12/26/2022]
Abstract
Patients with chronic kidney disease (CKD) have a high risk of hyperkalemia, which increases mortality and can lead to renin–angiotensin–aldosterone system inhibitor (RAASi) dose reduction or discontinuation. Patiromer, a nonabsorbed potassium binder, has been shown to normalize serum potassium in patients with CKD and hyperkalemia on RAASi. Here, patiromer's onset of action was determined in patients with CKD and hyperkalemia taking at least one RAASi. After a 3-day potassium- and sodium-restricted diet in an inpatient research unit, those with sustained hyperkalemia (serum potassium 5.5 – under 6.5 mEq/l) received patiromer 8.4 g/dose with morning and evening meals for a total of four doses. Serum potassium was assessed at baseline (0 h), 4 h postdose, then every 2–4 h to 48 h, at 58 h, and during outpatient follow-up. Mean baseline serum potassium was 5.93 mEq/l and was significantly reduced by 7 h after the first dose and at all subsequent times through 48 h. Significantly, mean serum potassium under 5.5 mEq/l was achieved within 20 h. At 48 h (14 h after last dose), there was a significant mean reduction of 0.75 mEq/l. Serum potassium did not increase before the next dose or for 24 h after the last dose. Patiromer was well tolerated, without serious adverse events and no withdrawals. The most common gastrointestinal adverse event was mild constipation in two patients. No hypokalemia (serum potassium under 3.5 mEq/l) was observed. Thus, patiromer induced an early and sustained reduction in serum potassium and was well tolerated in patients with CKD and sustained hyperkalemia on RAASis.
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